Post-intervention Care Research Articles

Implementation and Evaluation of a Network-Based Pilot Program to Improve Palliative Care in the Intensive Care Unit

Background Intensive care unit (ICU) care could be improved by implementation of time-triggered evidence-based interventions including identification of a patient/family medical decision maker, the patient’s advance directive status, and cardiopulmonary resuscitation preferences by Day 1; offer of social work and spiritual support by Day 3; and a family meeting establishing goals of care by Day 5. We implemented a program to improve care for ICU patients in five Department of Veterans Affairs’ ICUs. Measures We measured the percent of ICU patients with lengths of stay of five or more days that received the care processes by the appropriate day. Intervention Critical care and palliative care providers trained ICU nurse teams to improve care through auditing, performance feedback, improvement tools, education, and monthly team meetings. Outcomes Pre- and postintervention care were compared. Offering social work and spiritual support, identification of the medical decision maker, and documentation of family meetings significantly improved. Conclusions/Lessons Learned ICU nurse teams can be engaged to improve care under the aegis of a collaborative quality improvement project.

93. Pain in older men is associated with interleukin (IL)-6 change across time following a mindfulness-based stress reduction intervention

There is increasing evidence that mindfulness-based interventions reduce psychological distress in various medical populations. However, it has hardly been studied if these effects are mediated by an increase in mindfulness. The aim of this study was to examine mediating effects of various mindfulness facets on effects of a Mindfulness Based Cognitive Therapy (MBCT) on perceived stress and mood.Outpatients with diabetes types 1 and 2 and low levels of emotional wellbeing were randomized into a group receiving MBCT (n = 70) or a waiting-list control group (n = 69). Primary outcomes were mood and perceived stress. Before, after and at follow-up (6 months post intervention) relevant questionnaires were completed.Mediation analysis using bootstrap resampling indicated that increases in total mindfulness and the facets observing and nonreactivity mediated the effects of the intervention on depressed and angry mood, anxiety (only observing), and perceived stress (only nonreactivity) from pre- to post-intervention. In contrast, from post-intervention to follow-up, besides total mindfulness the facets of acting with awareness and nonjudging mediated the effects on depressed, anxious, and angry mood, while only nonjudging mediated the effects on perceived stress.The findings indicate that increases in levels of mindfulness mediate the effects of the Mindfulness-Based Cognitive Therapy in patients with diabetes. It is notable that different facets may be important for immediate change versus long-term outcome. These findings might be relevant for post-intervention care.

An Internet‐Based Communication Network for Information Transfer During Patient Transitions from Skilled Nursing Facility to the Emergency Department

To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. Interventional; before and after. ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF). All patients transferred from the SNF to the ED over 16 months. An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions. Nine elements of patient information assessed before and after intervention through chart review. changes in efficiency of information transfer and staff satisfaction. Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention. The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.

Aortic root dynamics and surgery: from craft to science

Since the fifteenth century beginning with Leonardo da Vinci's studies, the precise structure and functional dynamics of the aortic root throughout the cardiac cycle continues to elude investigators. The last five decades of experimental work have contributed substantially to our current understanding of aortic root dynamics. In this article, we review and summarize the relevant structural analyses, using radiopaque markers and sonomicrometric crystals, concerning aortic root three-dimensional deformations and describe aortic root dynamics in detail throughout the cardiac cycle. We then compare data between different studies and discuss the mechanisms responsible for the modes of aortic root deformation, including the haemodynamics, anatomical and temporal determinants of those deformations. These modes of aortic root deformation are closely coupled to maximize ejection, optimize transvalvular ejection haemodynamics and-perhaps most importantly-reduce stress on the aortic valve cusps by optimal diastolic load sharing and minimizing transvalvular turbulence throughout the cardiac cycle. This more comprehensive understanding of aortic root mechanics and physiology will contribute to improved medical and surgical treatment methods, enhanced therapeutic decision making and better post-intervention care of patients. With a better understanding of aortic root physiology, future research on aortic valve repair and replacement should take into account the integrated structural and functional asymmetry of aortic root dynamics to minimize stress on the aortic cusps in order to prevent premature structural valve deterioration.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches. In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data. From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained. We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.

Interdisciplinary treatment of diabetic foot syndrome

The amputation rate in patients with diabetic foot syndrome (DFS) in Germany is still as high as 28,000 per year. Ischemia and osteomyelitis often complicate the DFS. Impaired wound healing frequently requires further surgery with a higher amputation level. The results of treating patients with DFS in our specialized foot care center were evaluated in order to assess our interdisciplinary strategy. Advanced diabetic foot wounds in patients with ischemia and osteomyelitis first require diagnostics concerning polyneuropathy, osteomyelitis, and blood supply. If peripheral arterial vessel disease is present, surgical revascularization by distal bypass grafting is the first and crucially important element of the interdisciplinary approach. Minor amputation or elective resection of the infected bone improves wound healing. Post-interventional care for wounds with secondary healing and prevention of new ulcers are provided in a foot care clinic specialized in diabetes. The clinical and radiological results of 77 patients who underwent this treatment algorithm including bypass surgery and bone resection within 1 year were collected using a standardized questionnaire. Those results were subjected to a historical comparison. Only three patients needed further intervention because of persisting ulcers and osteomyelitis. The frequency of major amputations in all patients with DFS and ischemia combined with osteomyelitis was low (10.3%). This interdisciplinary concept of treatment guarantees a high healing rate in patients even with osteomyelitis and ischemia and allows the reduction of the rate of major amputations. The data obtained allow a fact-based design for future studies.

Interdisciplinary diagnosis and therapy of ischemic-osteomyelitic diabetic foot syndrome

Advanced stages of the diabetic foot syndrome complicated by ischemia and osteomyelitis frequently result in minor amputation, followed by impaired wound healing and higher-level amputation in the context of regular health structures. Even in specialized foot care centers, peripheral arterial occlusive disease and osteomyelitis still represent the greatest challenge in the strife for limb salvage. Whereas the treatment of nonischemic foot lesions has increasingly become a matter of conservative medicine within recent years, for advanced diabetic foot wounds a multidisciplinary treatment policy is essential. A well-coordinated treatment concept aiming at the elimination of the most relevant prognostic factors ischemia and osteomyelitis is required to achieve high limb salvage rates. Surgical revascularization by distal bypass is a crucially important element of this approach. Percutaneous transluminal angioplasty represents a complementary option for short-segment arterial occlusive disease. Foot-sparing minor surgery improves healing time and rates. A specialized diabetologic foot care clinic provides preclinical diagnosis, planning of inpatient procedures, and selection of patients requiring hospitalization for surgical intervention. In addition, it safeguards postinterventional care for wounds with secondary healing and measures of secondary prevention.